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Among infants who survive H in uenzae meningitis, Ferry and coworkers, in a prospective study of 50 cases, found that about half were normal, whereas 9 percent had behavioral problems and about 30 percent had neurologic de cits (seizures or impairment of hearing, language, mentation, and motor function) In a report of a personal series of 185 children recovering from bacterial meningitis, Pomeroy and associates found that 69 were still not normal neurologically at the end of a month; however, at the end of a year, only 26 demonstrated neurologic abnormalities; 18 were left with a hearing de cit, 13 with late afebrile seizures, and 8 with multiple de cits The presence of a persistent neurologic de cit was the only independent predictor of later seizures Dodge and colleagues found that 31 percent of children with pneumococcal meningitis were left with persistent sensorineural hearing loss; for meningococcal and H in uenzae meningitis, the gures were 105 and 6 percent, respectively Cranial nerve palsies other than deafness tend to disappear after a few weeks or months Deafness in these infections is due to suppurative cochlear destruction or less often to the ototoxic effects of aminoglycoside antibiotics Bacteria reach the cochlea mainly via the cochlear aqueduct, which connects the subarachnoid space to the scala tympani This occurs quite early in the course of infection, hearing loss being evident within a day of onset of the meningitis; in about half such cases, the deafness resolves Hydrocephalus is an infrequent complication that may become manifest months after treatment and then requires shunting if gait or mentation is affected It may be dif cult to determine on clinical grounds whether a residual state of imbalance is the result of hydrocephalus or of eighth nerve damage The acute complications of bacterial meningitis, the intermediate and late neurologic sequelae, and the pathologic basis of these effects are summarized in Table 32-1 Other aspects of current treatment have been well summarized by Lambert.

Quite apart from acute and subacute bacterial endocarditis, which may give rise to cerebral embolism and characteristic in ammatory reactions in the brain (see further on), there are several systemic bacterial infections that are complicated by a special type of encephalitis or meningoencephalitis Three common ones are Mycoplasma pneumoniae infections, Listeria monocytogenes meningoencephalitis, and Legionnaire disease Probably Lyme borreliosis should be included in this category, but it is more chronic and is described further on in this chapter with the spirochetal infections The rickettsial encephalitides (particularly Q fever), which mimic bacterial meningoencephalitis, are also addressed later in the chapter Cat-scratch disease is another rare cause of bacterial meningoencephalitis Meningoencephalitis due to brucellosis occurs very rarely in the United States Whipple disease, discussed below, which appears to be a focal invasion of the brain by a novel bacterium, is an oddity but also belongs in this category Mycoplasma pneumoniae Infections This organism, which causes 10 to 20 percent of all pneumonias, is associated with a number of neurologic syndromes Guillain-Barre polyneuritis, cra nial neuritis, acute myositis, aseptic meningitis, transverse myelitis, global encephalitis, seizures, cerebellitis, acute disseminated (postinfectious) encephalomyelitis, and acute hemorrhagic leukoencephalitis (Hurst disease) have all been reported in association with

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mycoplasmal pneumonias or with serologic evidence of a recent infection (Westenfelder et al; Fisher et al; Rothstein and Kenny) We have observed several patients with striking cerebral, cerebellar, brainstem, or spinal syndromes incurred during or soon after a mycoplasmal pneumonia or tracheobronchitis In addition to the cerebellitis, which is clinically similar to the illness that follows varicella, unusual encephalitic syndromes of choreoathetosis, seizures, delirium, hemiparesis, and acute brain swelling (Reye syndrome) have each been reported in a few cases The incidence of these complications has been estimated as 1 in 1000 mycoplasmal infections, but it may approach 5 percent when more careful surveillance is carried out during epidemics A severe prodromal headache has occurred in most of our cases At the time of onset of the neurologic symptoms, there may be scant signs of pneumonia, and in some patients, only an upper respiratory syndrome occurs The mechanism of cerebral damage that complicates mycoplasmal infections has not been established, but recent evidence suggests that the organism is present in the CNS during the acute illness To our knowledge, the organism has been cultured from the brain in only one fatal case, but PCR techniques have detected fragments of mycoplasmal DNA in the spinal uid from several patients (Narita et al) In other instances, the nature of the neurologic complications and their temporal relationship to the mycoplasmal infection clearly suggest that secondary autoimmune factors are operative; ie, that these are instances of postinfectious encephalomyelitis (a type of acute disseminated encephalomyelitis described in Chap 36) Most of the patients with the infectious variety have recovered with few or no sequelae, but rare fatalities are reported The CSF usually contains small numbers of lymphocytes and other mononuclear cells and an increased protein content The diagnosis can be established by culture of the organism from the respiratory tract (which is dif cult), by rising serum titers of complement- xing IgG and IgM antibodies and cold agglutinin antibodies in the blood and CSF, or by specialized DNA detection techniques from the CSF Treatment Erythromycin and tetracycline derivatives reduce morbidity, mainly by eradicating the pulmonary infection, but the effects of antibiotics on the nervous system complications are not known Listeria monocytogenes Infections Meningoencephalitis from this organism is most likely to occur in immunosuppressed and debilitated individuals and is a well-known and occasionally fatal cause of meningitis in the newborn Meningitis is the usual neurologic manifestation, but there are numerous recorded instances of an isolated focal bacterial infectious encephalitis, rarely with a normal CSF, most cases showing a pleocytosis that may be initially polymorphonuclear Between 1929, when the organism was discovered, and 1962, when Gray and Killinger collected all the reported cases, it was noted that 35 percent of 467 patients had either meningitis or meningoencephalitis as the primary manifestation The infection may take the form of a brainstem, or rhombencephalitis more speci cally, several days of headache, fever, nausea, and vomiting followed by asymmetrical cranial nerve palsies, signs of cerebellar dysfunction, hemiparesis, quadriparesis, or sensory loss Respiratory failure has been reported Of 62 cases of Listeria brainstem encephalitis reported by Armstrong and Fung, 8 percent were in immunosuppressed patients, meningeal signs were present in only half the patients, and the spinal uid often showed, misleadingly mild abnormalities CSF cultures yielded.

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